Can Indomethacin Be Given for Bilateral Sacroiliitis?
Yes, indomethacin and other NSAIDs are strongly recommended as initial treatment for bilateral sacroiliitis, providing both analgesic and anti-inflammatory benefits to control sacroiliac joint inflammation. 1, 2
Initial Treatment Approach
NSAIDs represent the first-line therapy for active sacroiliitis, with this recommendation holding strong despite very low quality of direct pediatric evidence, based on established utility in adult spondyloarthritis and known analgesic effects. 1, 2 The American College of Rheumatology guidelines explicitly support NSAID use as initial treatment over no treatment for both adult and pediatric populations with sacroiliitis. 1
Indomethacin specifically has demonstrated long-term tolerability and efficacy in chronic inflammatory arthritis conditions, including ankylosing spondylitis (which commonly presents with sacroiliitis), with average daily doses of 75-100 mg showing good control of active inflammation. 3
Treatment Algorithm
- Start with NSAIDs (including indomethacin) at optimal anti-inflammatory doses as first-line therapy 2
- Evaluate response after 2-4 weeks of consistent NSAID therapy 2
- If inadequate response to NSAIDs alone, strongly recommend adding TNF inhibitor therapy (etanercept, adalimumab, infliximab, or golimumab) over continuing NSAID monotherapy 1, 2
- For patients with contraindications to TNFi or who have failed multiple TNFi, conditionally recommend sulfasalazine 1, 2
Adjunctive Therapies During NSAID Treatment
Bridging glucocorticoids (<3 months duration) are conditionally recommended during NSAID initiation, particularly when high disease activity, limited mobility, or significant symptoms are present. 1, 2
Intraarticular glucocorticoid injections directly into the sacroiliac joints can be used as adjunct therapy, with research showing higher pain relief rates in the first week compared to NSAIDs alone, though without long-term disease activity modification. 1, 4
Physical therapy is conditionally recommended for patients with or at risk for functional limitations to maintain range of motion and strengthen periarticular muscles. 1, 2
Critical Considerations
Avoid methotrexate monotherapy for sacroiliitis treatment, as it is strongly recommended against based on adult spondyloarthritis data showing lack of effectiveness, though it may serve as adjunct therapy for concomitant peripheral polyarthritis. 1, 2
Avoid systemic glucocorticoids as monotherapy or long-term treatment; they should only be used as short-term bridging therapy (<3 months) during treatment escalation. 1
The evidence supports indomethacin as an appropriate NSAID choice, with objective measures like quantitative sacroiliac scintigraphy demonstrating its ability to reduce inflammation in active sacroiliitis. 5